- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.96 / $931.96 / $931.96
| Professional | | $931.96 | $931.96 | $931.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.00 / $2,185.00 / $2,731.00
| Professional | | $1,821.00 | $2,185.00 | $2,731.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.41 / $1,560.47 / $2,200.67
| Professional | | $1,262.41 | $1,560.47 | $2,200.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.90 / $2,342.25 / $3,632.62
| Professional | | $1,461.90 | $2,342.25 | $3,632.62 |